To say that Medication Adherence is a hot topic in many pharmacies is an understatement. With the Proportion of Days Covered (PDC) being the focus of three of the five CMS performance measures for pharmacy, medication synchronization services are being adopted by many pharmacies. Synchronization is one strategy to improve patient compliance, making it less likely that the patient runs out of medication.
At our pharmacy, the synchronization is often referred to “not-so-simplify my meds” because of all of the details that have to be managed by the pharmacy to successfully synchronize, and maintain synchronization, of a patient’s medications. Companies like Prescribe Wellness, and Ateb (and others) offer cloud based software solutions to help pharmacies manage what turns out to be this less than trivial task.
But synchronization only address one aspect of patient compliance by making it less likely that the patient will be without one or more medications. The patient still has to remember to follow their mediation regimen, and sometimes this obstacle is daunting. Pharmacist can coach patients to improve their compliance or even suggest changes of therapy to the prescriber to simplify the patient’s medication regimen (e.g. changing a person from simvastatin, that has to be taken in the evening, to atorvastatin, that can be taken with the rest of the patient’s medications). When these types of interventions steps fail to improve a patient’s compliance, however, it is time to call in a super hero: SuperSync.
Med Planners
One of the best ways to help a patient take their medications correctly is the make the job of taking the medications less burdensome. An easy way of doing this is to recommend the use of a medication planner. Filling a planner, however, is a fairly tedious process for some patients. The pharmacy can assist (though it does need to abide by state and federal regulations with respect to labeling if applicable). Depending on how this service is managed, it is even possible for the pharmacy to charge a fee for this service.
SuperSync: Synchronization plus Packaging
One novel way to approach medication packaging for the synchronized patient is to do away with the prescription vial entirely. Packaging systems like the Parata Pass system create a prepackaged, commingled, multi-dose strip package with each day and time divided into a perforated strip of bags. The patient’s next doses are always the next bag on the strip.
Methods like this work very well in combination with medication synchronization. The patient’s medication are simply entered in the pharmacy management software and sent to the robot for packaging. The pharmacy trades vials, caps and labels for the disposables used by the packaging system.
Cost Analysis
One significant question, however, is if a program like this will save a pharmacy money, or cost them more in time and materials. The analysis below represents reasonable approximations to the cost of this type of program.
Traditional Prescriptions
The cost of a typical prescription vial with a lid varies by size, with the more common small 8 dram vials / lid costing roughly $0.25 each. Larger vials can cost upwards of $1.00, though these are much less commonly used in most pharmacies. Label costs add about $0.02 to $0.08 each, depending on stock and size of the order. Overall, each prescription filled costs the pharmacy about $0.30.
The cost per month for vials, lids and labels, given a typical patient being synchronized in our pharmacy is about $3 per month. When dispensing 90 day supplies, the cost per month is reduced only marginally, as the more of the larger vials are required, adding expense.
Strip Packaging (commingled)
The primary costs associated with this method are packaging paper (the cellophane that becomes the bag) and the ribbon (which creates the printing on the package). The cost of the robotic equipment is not being included in this discussion in a similar way that labor costs were not included in the cost analysis of a traditional prescription. The per-bag cost for a strip-package is about $0.021 (the decimal is important as there will be numerous bag in any given order).
The number of bags in an order will depend on the number of medications, and the number of times each day a patient takes a medication, and the number of days being packaged. Each bag is capable of holding up to four different medications (this is a practical limitation based on the size of print and the amount of information that has to be included on each bag per pharmacy labeling regulations) and seven tablets/capsules (this being limited by the volume each bag can contain).
Because each bag can hold any combination of 4 medications and 7 tablets / capsules, the typical day will include 1 to 4 bags. For example, a patient taking 6 medications (representing 7 tablets), all in the morning, would require 2 bags per day to allow for the printed requirements to fit on the packaging. If one of those medications were twice a day, they would require 3 bags per day. Patients with medications taken three or four times a day will have as many as eight bags a day. This means that the average cost to the pharmacy in disposable overhead is about on par with traditional prescription vial based packaging for most patient needs.
Kryptonite for SuperSync
The biggest disadvantage to a packaging system like the Parata Pass being married to a synchronization program is the potential for therapy changes. If a patient has a medication change, the entire strip is potentially rendered incorrect. It would need to be re-packaged, adding additional costs in labor and overhead. It is important to keep this in mind when selecting patients for a SuperSync type program. Policies and procedures also have to be developed to handle this type of change, as even the most stable patient can have a change that effects their meds when they are packaged in this manner.
Workflow and Equipment
The two biggest challenges with using a SuperSync process are:
- Purchasing the equipment and
- creating a workflow that is efficient and seamless.
Equipment like the Parata Pass are capital purchases involving many tens of thousands of dollars both in up front costs and reoccurring maintenance fees. Traditionally, this type of packaging has been used mostly in nursing home type pharmacies. The congruence of packaging and synchronization, however, makes it appealing for retail pharmacies as well. I am aware of more than a few pharmacy practices that are adopting this type of packaging for all of their ambulatory patients. Workflows that leverage both synchronization and robotics like the Parata Pass have the potential be extremely efficient.